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UVA Health teams from orthopedics, peri-anesthesia, post-anesthesia, and physical therapy (PT) are marking one year since launching a collaborative pilot aimed at redesigning the discharge process for total joint replacement patients. “Due to ongoing capacity issues within the hospital, leadership continually is looking at ways to free up space with inpatient areas,” explains Katherine Kois, MSN, RN, PCCN, Manager, PeriAnesthesia Main.

Led by Rebekah Melan, MSN, RN, ONC, Nurse Manager, 6 East — the pilot focuses on expanding same-day discharges directly from the Post-Anesthesia Care Unit (PACU) while maintaining safety and consistency.

“6 East consistently discharges more than half of our 30-bed unit on any given day,” Melan explains. “Given the ongoing increase in hospital capacity demands, it was appropriate to identify total joint patients — who typically discharge either the same day or on post-op day — as an ideal population to transition to Extended Stay, rather than being admitted to an inpatient unit.”

Identifying Correct Patients from the Start

At the UVA Health Orthopedic Center at Ivy Road (OCIR), same-day discharge is already a well-established process. With inpatient beds in high demand at University Medical Center, the pilot adapted that model to a new setting. Angel Cyphert, RN, Nurse Director, PeriAnesthesia Services Main OR, helped lead the charge, ensuring the PACU is equipped with the staff and space to support extended stays post-surgery.

On the ambulatory side, Total Joint Replacement Clinical Program Coordinator, Amber Dillon, MSN, RN, worked with RN care coordinators to identify patients suitable for same-day discharge.

On a unit as large and complex as 6 East, with often higher acuity patients than at OCIR, implementing a new program took true teamwork. “The program’s success highlights the partnership with our inpatient and ambulatory orthopedic colleagues as well as our provider group’s dedication to their teams,” Kois says. 

Dillon agrees, saying this was a joint effort involving many team members within the joint replacement department that started with the development of same-day medical and social discharge exclusion criteria by the joint replacement surgeon and anesthesia group for patients undergoing joint replacement surgery at the main hospital. "The RN care coordinator team used those criteria to identify eligible patients and gauge their interest in going home the same day. They also considered factors like discharge destination and social support. That let us tailor the list of candidates and get the care teams aligned early.”

Early Mobilization: A Key to Going Home

A crucial part of same-day recovery is early mobilization, supported by the PT team. Physical therapist Kohl Kershisnik, PT, helped train PACU staff and guided patients through early movement. “A multidisciplinary approach to mobilization is very important because these patients are trying to discharge the same day after surgery. I was able to contact the PACU and Extended Stay PACU to set up education and hands-on training, which ensures that every team member feels confident in mobilizing this patient population before discharge.”

“We want to see that vital signs are stable, patients can go to the bathroom, and that they feel good with their home exercise program,” Kershisnik adds. “We also practice stairs, review car transfers, and ensure they have their next phase of rehabilitation and the equipment they need to succeed at home. All of this information is relayed to the case manager and nurse practitioner to start the discharge process.”

To make this new process work, PT extended hours of availability. “Before this project, PT was available until 6 p.m., so patients with a later operating room (OR) time often spent the night to be evaluated by therapy the next day. By expanding our availability to 8 p.m., we now facilitate patients with later OR times, in being able to discharge the same day if medically appropriate.”

Kershisnik also gives credit to his colleagues: “I would like to recognize the two other therapists who have helped to make this project a success: Catherine Kelly, who has been a member of the orthopedics PT team at UVA health for more than nine years and Dan Gulbransen, who changed his shift to 8 p.m. to see those patients with later OR times.”

Easing Bottlenecks, Enhancing the Patient Experience

While 6 East is already known for its efficient same-day discharges, the pilot also aimed to reduce transfers and bed bottlenecks. “Even though we often discharge patients within four hours, many are still placed on other units due to bed constraints on 6 East,” Melan explains. “Avoiding unnecessary transfers improves both operational flow and the patient experience.” 

She adds that this initiative required significant collaboration, dedication, and engagement from team members across the organization. "It’s through this process that I gained a deeper appreciation for the unique workflows and challenges faced by different areas — something that only becomes clear when you’re immersed in the details of their day-to-day operations. I’m sincerely grateful to everyone involved, especially Rachel Ward, RN, MSN, CNL, Be Safe coach; Renee Wilson, AGACNP-BC, orthopedic NP; and the PT team, whose flexibility and commitment are vital to meeting patients' needs.”

Looking Ahead: Strengthening Our Foundation

Thanks to the new same-day discharge process, patients coming from the Emergency Department or other parts of the organization that need higher acuity beds are now able to go to those areas. In addition, the new program gives many joint replacement patients the chance to go home earlier and allows them to stay on the same floor from pre-op to discharge.

“What I love about the PACU is how the team works together as one unit to take care of patients and give them the best quality care,” says Anika Spry, RN, Nurse Manager, PACU, who has been with University Medical Center for more than 20 years. “I think this change is really making the patients’ experience better.”

For Dillon, the project is about expanding what already works well. “It’s exciting to apply a process we’ve been using at OCIR to a secondary location,” she says. “The development of an alternative discharge pathway for the patients undergoing surgery at our main hospital location will benefit our patients and improve our efficiencies.” 

As the pilot continues, teams are focused on refining communication and support systems — all designed to give patients a safe, seamless path from surgery to home, often in a matter of hours.

Other team members who were key to the project’s success: 

• James Browne, MD, Orthopedic Surgeon
• Lara Demers, PT, DPT, Director of Rehabilitation Services
• Alison Okerlund, MSN, RN, CCRN-K, Director of Orthopedic, Neuro, and Behavioral Health Nursing Services
• Ainsley Polson, RN, Ambulatory Clinic Manager
• Regina Ragland, RN, OCIR Perioperative Assistant Nurse Manager and super trainer
• Chris Smith, PT, DPT, Physical Therapy Manager
• Peri-anesthesia main management team: Pam Redman, RN; LaShanda Baker, RN; Casey Jackson, RN; and Ashley O’Keefe, RN
• Main nursing team "super trainers": Samantha Maddox, RN; Patricia Berkin, RN, BSN, CMSRN; Melissa Johnson, RN; Elbia Thornton, RN; and Kim Wood, RN